UK Community Pharmacist

Dr Crippen and Quackitioners

2008-02-05T21:58:00.000Z

We all know that Dr Crippen of NHS Blog Doctor doesn't like nurse practitioners, who he so kindly refers to as 'quacktitioners', but now he has taken a pot shot at pharmacist with a special interest(PHwSI). Now just in case Dr Crippen doesn't realise this, pharmacists do four years at uni, followed by a years on the job training (a pre-registration year). To become a PHwSI you would no doubt have to do a clinical diploma which takes another two years, and most pharmacists don't start these just after registration. So a minimum of six years training until a pharmacist could be a PHwSI. Lets not also forget that pharmacists get taught far more about drugs than doctors do - we don't really have to worry to much about diagnosis.

Dr Crippen comes across as a GP who has been qualified for quite a while and seems to take the view that no one can do any job better than a medically trained person. But how good are GPs at dermatology? My experience is that they are not that good - I've spoken to a GP with a special interest in dermatology who complained that GPs were prescribing oral antibitotics for acne without a topical treatment, and I've also had a patient who I found out was using Fucibet (fusidic acid, which is an antibiotic, and betamethasone which is quite a strong steroid) on her face! Dermatology is also an area that is conducive to management by people other than doctors - I'm no dermatology expert but I generally see at least one skin rash per day and normally have a decent idea of what it is and how to treat it, and those patients I send to their GP normally come back with a prescription for what I was expecting.

The question is why is Dr Crippen so defensive and so against pharmacists or nurses looking after certain conditions. What would he think if he knew that I was responsible for the care of some patients on warfarin?

At the end of the day there are lots of patients out there with chronic diseases. Doctors, pharmacists and nurses should be working together to look after these patients, after all there are more than enough of them to go round, and GPs can get money from work done by other people (I've got 80 COPD patients to check inhaler technique for, so that the GP practice can get their QOF points). Pharmacists are not generally diagnosticians, (PHwSI may be an exception) but we are eminently qualified to look after patients with established diseases.

I'm back

2008-02-05T21:37:00.000Z

Sorry for the long absence, but lots of things have been going on since the summer. I've left the branch I was managing (for a number of reasons), did some relief work across the south east for a few months and am now at one branch full time because I've replaced one of my friends who has gone back to Australia to study medicine as a postgrad. The bonus is that my trip to work is about 30 seconds as I'm living in the flat above the pharmacy.

I've also been busy with my clinical diploma and all is going well. The exam was a few weeks ago and seemed to go ok, apart from a question on baby milks. I also have a new girlfriend, so am very happy and content at the moment.

I'll try and post more regularly in the future as I get back into the habit. The branch I'm at now does 20,000 items a month, so we have quite a few interesting patients to discuss.

50% increase! Are you having a laugh?

2007-07-31T22:27:00.001+01:00

I've just found out that my retention fee for the Royal Pharmaceutical Society is increasing from £283 this year to £425 next year. Yes, we were warned about a 'significant increase' , but 50% is a bit more than a significant increase! Not only is the increase bad enough, but the Society is still way behind the times. Retention fees are payable in full at the start of January - there is no option to spread them over the year. Apparently this is because the bylaws say that retention fees have to be paid in full by a certain date. Well change the bloody bylaws then! Still, it should be about the only time minutes from council meetings are interesting and worth reading.

The Welsh Pharmacist has a more, erm, acerbic take on this.

Mark Cheesman has also set up a petition, demanding the Society reconsiders the increase in retention fees.

Interesting patients

2007-07-31T21:35:00.000+01:00

A lot of my job has the potential to be quite monotonous. Most diabetics, hypertensives and asthmatics are managed according to national guidelines, for example. Every now and then though you get a really interesting patient. I've had a couple of these patients over the last few months.

One lady, lets call her Jennifer, has a complicated pain management regimen. Not only is Jennifer on modified release oxycodone and immediate release morphine, which is strange enough, she is also on fentanyl lozenges. I had never dispensed fentanyl lozenges before, so had to make some phone calls to find out some information about the equivalence between fentanyl lozenges and oral morphine. I have no idea why Jennifer is on three different opioid painkillers - patients are normally on a prolonged release and immediate release version of only one, as it makes adjusting the dose a lot easier.

Another lady, lets call her Emma, is being treated for toxoplasmosis. Toxoplasmosis is caused by a parasite found in undercooked meat and in cat faeces. Normally infection does not cause any problems and is dealt with by the body's immune system. However, the infection can sometimes spread to the eye and cause problems. It looks like this is what happened in Emma's case, as the prescription for her treatment was written by a consultant opthalmologist, who helpfully left his mobile phone number on the prescription. Toxoplasmosis is normally treated using a combination of pyrimethamine and sulfadiazine, neither of which are common stock in community pharmacy. Patients are also given folinic acid, to reduce the side effects of the treatment. I also had someone on the phone from the hospital pharmacy department a few days later wanting to check whether the prescription was for folic acid. I seriously hope it was a technician and not a pharmacist, but don't hospitals have copies of Martindale?

I've also had another patient, James, who has been off somewhere exotic and come back with schistosomiasis, a nice little parasitic infection caused by flukes. Now we don't get too many cases of this in the UK, and there is not actually a medicine on the UK market to treat it. The recomended treatment is with praziquantel, which has to be ordered directly from Merck, the manufacturers. James needed six tablets. Praziquantel comes in a pack of 90, costing over £300, and although I can claim payment for the whole pack I am now left with 84 of these tablets sitting on my shelf until they go out of date.

Oh, and I also have a couple of patients on Glivec, at a cost of about £1500 per month each to the NHS. Glivec is a very good and groundbreaking drug, but it is not cheap.

Product advertising

2007-06-02T22:37:00.000+01:00

Now this is a certainly an interesting way to advertise your product.

Viagra

2007-06-02T22:35:00.000+01:00

This cartoon is so true

£100m worth of drugs wasted each year

2007-05-19T00:03:00.000+01:00

The BBC and the Guardian have both run a story about £100m worth of drugs being wasted each year by patients. I'm shocked. Shocked that it's only £100m per year. The real figure is going to be far higher. I have returned medicines collected every couple of months by a contractor. They normally take away seven or eight sackfuls of drugs - thousands of pounds worth. As an example, I have had two boxes of Casodex (at £240 per box), two seretide 250/25 inhalers (£75 each) and 30 diamorphine ampoules returned recently. Once something has left the pharmacy it can't be reused. There are two reasons for this. Firstly I don't know how it has been stored, and secondly I have already claimed payment for the drugs.

Some waste is unavoidable - people die, patients react badly to certain drugs. But waste can be reduced. The easiest way to reduce waste is to prescribe a months worth at a time. This also has the useful benefit of training the patients in how long it takes a prescription to be generated - they tend to forget if they only have to do it once every three months. Two or three monthly prescribing falls down because patients stockpile drugs and GPs don't always change their records. For example, someone is started on a new blood pressure tablet and is given 28 days supply (which is reasonable enough). They tolerate this new drug and their blood pressure comes down to target. However, the surgery forget to change the quantity to three months on the repeat screen. So Mrs Smith ends up with 28 days of bendroflumethiazide, 84 days of ramipril, 56 days of simvastatin, 84 days of omeprazole and 100 aspirin on her repeat prescription. And these all get ordered every month because Mrs Smith ticks all the boxes (or doesn't tick any and the surgery issue everything). This doesn't get picked up by the GP signing the prescription, and is tough for the pharmacist to pick up as well - I deal with 10,000 items per month; I don't have the time to look at every patient's records to see when they last had their drugs.

28 day prescribing also saves money - it stops people going to their GP for prescriptions for hayfever treatment for example. It is cheaper to pay the £6.85 prescription charge for two or three months worth of cetirizine than to buy it over the counter. If the prescription is only for 28, it is cheaper to buy it over the counter. I have been seeing lots of prescriptions recently for 90 cetirizine or 2 beconase nasal sprays, and it irritates me greatly.

Also mentioned in the above stories was the fact that £200m was wasted by GPs prescribing branded drugs over generic ones. The National Audit Office looked at prescribing of statins, ACE inhibitors, PPIs and clopidogrel, which account for 20% of prescribing costs between them. There are cheap and effective generic statins, ACE inhibitors and PPIs available. For example, simvastatin 40mg daily reduces cholesterol by about the same as 10mg atorvastatin daily. But simvastatin costs £3.50 per month while atorvastatin costs £18 per month. So it makes sense to use simvastatin, other than in those patients who genuinely can't tolerate it. There is also more evidence to support the use of simvastatin than atorvastatin, such as the Heart Protection Study. Clopidogrel is more interesting. It does the same job as low dose aspirin, and is often used in combination with aspirin for a year after a heart attack. Except that the combination often carries on for more than a year. Clopidogrel is also used as an alternative to aspirin for those who can't take aspirin. However, clopidogrel is actually quite similar in terms of side effects when compared with aspirin. Clopidogrel costs around £30 per month, while aspirin costs around £1 per month.

For some reason I decided to read the comments on the BBC website. That was a bad move. It is just as well I am young, otherwise I may have had a heart attack, though I definitely feel the need to bash my head against a brick wall. My neighbours may be worried about me given the amount of abuse that was coming out of my mouth, and there were times I felt like chucking my laptop out of the window. Just to address one major point that came up. There is (virtually) no difference between generic and brand name drugs. It is not unusual for them to be manufactured by the same company - Merck owns Generics UK for example. There are certain drugs which should be prescribed by brand name, and there are a few people who are sensitive to different excipients in generics, but the vast majority of patients have no problem with generics. Generics should be used whenever possible because they are far cheaper than the original brand.

Coeliac disease

2007-05-09T22:27:00.000+01:00

Coeliac disease awareness week is coming up soon. Hence this story on the BBC website.

As it says, coeliac disease is a gut disease caused by gluten intolerance and the only treatment is a gluten free diet. So what? What is gluten? Gluten is a protein that is found in wheat, barley and rye. People with coeliac disease can't tolerate gluten - they may get diarrohea, bloating and weight loss . The presence of gluten causes an inflammatory reaction in the gut, leading to reduced absorption of nutrients and so the failure of a child to thrive may be due to coeliac disease.

But why is this a problem? Well, standard flour, as used in bread, cakes, pastries and so on is made from wheat. Therefore people with coeliac disease have to eat special gluten free products. Although some supermarkets carry a gluten free range they are more expensive than standard products, and so most coeliac patients get their foods on prescription. There is a wide range of gluten free foods available on prescription, ranging from long life breads to freshly baked breads. Pasta, biscuits, cake mixes and flours are also available on prescription.

Prescriptions for these products do occasionally cause problems. A typical prescription might read "Juvela gluten free wheat free white fibre loaf sliced". Juvela also do brown loaves, non-fibre loaves, non-sliced loaves, and so on. At least their products are long life though. Bigger problems arise when you order freshly baked products and are told they will arrive on a certain date. Of course you relay this information to the patient so they know when to collect their prescription. But then the bread does not turn up on the date you were given and you have to placate an irate patient...

Coeliac UK have a very useful website with lots of information on coeliac disease and gluten-free products and services.

The week after Easter

2007-04-11T22:07:00.000+01:00

In the run up to Easter normally sane people go a bit crazy, just because the GP surgery is going to be closed for four consecutive days. So it's fair to say that it's quite a busy week. Things normally calm down after easter - not for me though, this week has been even busier than last week.

Today has been interesting shall we say. Firstly I had to deal with a dispensing error made by one of the pharmacists who was covering me on my week off. Zispin 30mg had been given instead of 15mg, so the patient had been taking double the dose she should have been for about a week. Unsurprisingly she had been a bit drowsy, but I managed to sort things out for her. I then had a patient in with a subconjunctival haemorrhage. These look spectacular, but in most cases aren't anything to worry about. I've had one myself - I won't go into details but it involved contact lenses and alcohol.

I've also bent the rules a few times today. Firstly I did a medicines use review with the daughters of a patient. MURs are supposed to be done with the patient, but this patient was housebound and the daughters are in and out everyday anyway so are up to speed with what's going on. Next I dispensed some out of date medicines, intentionally. I had a prescription brought in for a lady who has not got too long left. It had diamorphine (heroin) and hyoscine on it. In terminally ill patients hyoscine is used to reduce respiratory secretions ('death rattle'). So it's something that is needed fairly quickly. I didn't have any in stock, but one of the other pharmacies near by did. The only problem was it went out of date a few days ago. Damn. I really didn't want to leave this lady overnight without the hyoscine. So I phoned the manufacturers who at least confirmed there were no toxic products produced when hyoscine degrades. Of course the manufacturer came out with their standard line of 'we don't recommend you use the product after the expiry date.' Well I know this, but I don't really have much choice at the moment do I?

Reporting of benefits

2007-04-09T21:10:00.000+01:00

I had an interesting study week on the diploma course I'm doing. One of the things we did during the week was to pick a couple of papers to pieces and look at how they discussed the results.

There are several ways the results of a study can be discussed. Obviously you have the raw numbers, but they are difficult to compare between studies. The three main ways of reporting the benefits of a treatment are relative risk reduction (RRR), absolute risk reduction (ARR) and numbers needed to treat (NNT). Relative risk reductions sound impressive, and are loved by the press and drug companies but they don't actually tell you very much. So you see headlines such as 'aspirin cuts risk of dying by 25%' or 'schoolkids use of drugs doubles'. RRR tells you, as the name suggests, the relative difference between the experiemental arm and the control arm, but, to know if this matters or not you need to know the background incidence of the event. Advertising departments of drug companies and the media often either hide away the background incidence or don't tell you it at all.

Absolute risk reductions are often small, just a few percent, and don't sound particularly impressive, but they tell you infinitely more than RRRs. Again, as the name suggests the ARR tells you the absolute difference between the control and treatment arms. However it can be difficult to translate how an ARR benefits patients. This leads on to the number needed to treat. Now the NNT does what it says on the tin. It tells you how many patients need to be treated for one to benefit and NNTs are very useful in comparing treatments.

Now for some examples. What if I told you there was an easy way to double your chances of winning the lottery? It's easy, just buy two tickets instead of one. But because your chances (or risk, or probability -they all mean the same thing) are vanishingly small to start with, doubling your chances still means they are vanishingly small: they are now just 1 in 15 million compared to the 1 in 30 million before. So the ARR in this case would be absolutely tiny. But now think about a school raffle where one ticket has a 1 in 100 chance of winning. Again there is an easy way to double your chances of winning by buying two tickets instead of one, but in this case your chances have increased significantly from 1 in 100 to 2 in 100, an absolute increase of 1%. Now the NNT is easy to calculate: it's 100/ARR. So if the ARR was 2%, you would need to treat 50 patients for one to benefit.

Sounds straightforward enough? (Or maybe not, depending how well I've explained it.) Well consider the following scenario: your hospital is considering four different cardiac rehabilitation programmes. You must choose which one you will implement. Reliable evidence shows that, during a three year period:
- Programme A reduced the rate of deaths by 20%
- Programme B produced an absolute reduction in deaths of 3%
- Programme C increased patient survival from 84% to 87%
- Programme D meant that 31 people had to enter it to prevent one death.

Which one would you choose?

This was actually the basis of a study performed by Fahey et al The figures above actually relate to the same data, just presented in different ways. Unsurprsingly they found that the programme that reported the RRR was the one chosen most often for funding.

The moral of the story is this: if you want to sell a drug report the RRR. If you want to know whether the drug is actually worth the money then look at the ARR and NNT (or speak to your prescribing advisor or community pharmacist if they are good)

Ben Goldacre probably explains this kind of thing far better than I do, and there is plenty of information on his website and in his Guardian columns.

Too funny

2007-04-09T21:06:00.000+01:00

A couple of recent stories that made me chuckle:
Holy water not that holy
Sign up to test condoms

Requirements for being a pharmacist

2007-03-21T20:12:00.000Z

1: being able to decipher illegible scrawls

I don't think I've ever recieved prescriptions as badly written as those, but some have come close.

Naughty nursing homes

2007-03-20T22:01:00.000Z

I got a phone call today from one of the nursing homes we look after:
'Mrs X has got four tablets in her nightime slot, she should only have three?'
Oh bugger....
'Ok, I'll send my driver out with a new tray and to pick up that one so we can figure out whats happened'

So we got the tray back later on. We eventually worked out that one of the members of staff at the nursing home had been tampering with the tray. This lady used to be on hydroxyzine (a sedating antihistamine), 1 or 2 at night when needed. These were supplied as they would be to any patient: we can't put them in a tray as we don't know when she would need them. Hydroxyzine was difficult to obtain a few months ago, so this patient was switched to zopiclone, another sleeping tablet.

Once we had figured out what had happened we spoke to someone senior at the home and explained the situation. This is a totally unacceptable situation: nursing homes shouldn't tamper with pre-packed medication provided from the pharmacy. The manager said they would look into it, and I would expect disciplinary action to be taken. I'm waiting to hear what happens.

I feel like a tennis ball....

2007-03-20T21:31:00.000Z

I had my mobile stolen the other day. At work. I'd taken all the stuff out of my jacket to put it in at the dry cleaners and had left my phone on top of my filling cabinet in my consulting room. And some little bastard helped himself to it. It was visible from the shop floor, so it's partly my fault, but its still bloody annoying. I just need to get some footage off the CCTV cameras. It wont actually show him taking it, (no camera in the consulting room) but may be of use to the police.

The real fun came when I tried to report it. I phoned the phone company: 'we need a crime reference or lost property number before we can do anything.'
I phoned the police: 'We need the IMEI number' (What???)
Back to the phone company to get the IMEI number
Back to the police: 'Has the phone been barred? Have any calls been made on it since its been taken? Can't give you a crime reference number until we know this.' I don't know, why didn't you ask me this when I first called???

Eventually back to the phone company. I actually get to speak to a decent person, who doesn't ask for a crime reference, sorts out a replacement handset for me, manages to keep the same number as before, and gives me all the details I need for the police. A replacement handset is either a £70 one off charge, or £30 and a 12 month subscription to their insurance policy at £6 per month (=£92). As this is the first phone I've lost in six years I think I'll take the first option.

The mobile phone company (Orange) only provide a 07 number to contact them on if you aren't calling from an orange mobile. The whole reason I'm phoning you is because I don't have my phone!!!! There were several times I called and got told there was a 20 minute wait to speak to someone. Nice little earner for them, though obviously I didn't hold the line (when do I have 20 minutes to hang on the phone at work?). When my contract is up I think I'll be moving elsewhere as I was not at all impressed by their customer service.

Busy, busy, busy!

2007-03-20T20:58:00.000Z

I just don't know where the last month and a half has gone. I've been so busy it's ridiculous and there have been so many things to comment on. I've had a contract monitoring visit (which actually went ok, considering) and I've had several pieces of coursework to do for the postgrad course I'm doing. I've got a study week coming up for this course - it'll be a nice break from the daily grind.

So, some things that have happened since my last post:
Oral contraceptive to be available over the counter? I don't think it'll happen. It will take up too much of my time and women can get it free from their GP and only need to see them once a year.

Weight loss drug Orlistat becomes available over the counter in America. A forerunner to an application in the UK? Probably. As I understand it you can get it from certain Boots pharmacies in the UK without a prescription (in a scheme called a patient group direction). Orlistat works relatively well, but patients' progress needs monitoring. Orlistat works because it stops the absorption of fat in the intestine. If you have more than about 40g of fat per day while taking orlistat the fat goes straight through you, literally.

Viagra available from Boots without a prescription. No thanks! £50 for 4 tabs (which strength?) and an hour with the pharmacist is not good business sense. I can make more than £50 per hour for the business by checking prescriptions. Erectile dysfunction needs to be investigated properly as it is often a forerunner for more serious conditions such as diabetes and angina.

Royal Pharmaceutical Society to split. Probably not of much interest to the general public, but it does bring us in line with other health professionals. Regulation will be done by a General Pharamaceutical Council (appointed by the government?), along the same lines as the NMC, GMC and GDC. Representation will presumably be done by a royal college type body, and hopefully they'll make a better fist of it than the Society does at the moment.

Pseudoephedrine to be made a prescription only medicine? The MHRA are consulting on a proposal to make pseudoephedrine a POM. This ingredient is present in many OTC cold and flu preparations and congestion preparations such as Sudafed. Pseudoephedrine is used in the manufacture of methylamphetamine ('Crystal Meth'). There is no evidence that pseudoephedrine to manufacture crystal meth is obtained from pharmacies - it would be far easier to obtain it in pure form from a manufacturer in somewhere like Mexico than from pharmacies in the UK. I am trusted to sell morphine and codeine over the counter, as well as the morning after pill and sumatriptan for migraines. Why can't I be trusted to sell pseudoephedrine?

'Banned' aditives in childrens medicines. Amazingly, given that I work in a fairly well heeled area I've not had any questions about this. Firstly the additives are banned in foods, not medicines. Medicines are different from foods as they are taken in small quantities and infrequently (normally). Their shelf life is also longer. Medicines for children are almost always liquids. These suspensions and solutions need preservatives to prevent microbes growing and to keep them stable. They also need to be flavoured so that the children will actually take them. Its difficult enough getting medicines down children even when they look and taste nice. Paracetamol, for instance, tastes foul, even when you get a tablet on your tongue. Anyone who has taken soluble paracetamol will know what I am talking about. Good luck trying to get that down a childs throat!

You think £20 for a prescription is expensive???

2007-02-02T00:11:00.000Z

I had a gentleman in today to pick up a prescription for himself and his wife. His wife's was a private prescription that costs around £20. He wasn't best pleased about this. He changed his mind somewhat when I took out his prescription and had a chat. His Rx was for Casodex 150mg tabs. These cost the NHS £240 per 28. He had two boxes - the cost of that on a private Rx would have been over £600 probably. His view on the £20 for his wife changed somewhat after that.

Another expensive script I've had this week was for 400 Prograf 1mg capsules. These cost the NHS £85 per 50. So not cheap. And to think some people who are well off moan about paying the £6.65 prescription charge.

Stupid things that patients do (1)

2007-01-29T22:23:00.000Z

An elderly gentleman purchased some ranitidine for heartburn today (training point number one for staff there - heartburn in the elderly needs medical investigation as it could be cancer or an ulcer). When asked if he was on any other medication he said he wasn't (training point number two: its not 'are you on any other medication', it's 'what other medication are you on'. The difference between closed and open questions is amazing).

Ten minutes later the gentleman came back, saying he felt guilty for lying to the staff. So I gave him a refund (shouldn't do, strictly speaking according to company policy) and sent him to his GP. When I looked at his medication history he was on warfarin, amongst other things. Now that's just the sort of thing you want to be on if you have got a bleeding gastric ulcer.

Patients are just so helpful sometimes.

CDs are such fun

2007-01-29T22:05:00.000Z

Thanks to that lovely Dr Shipman I now have to jump through so many hoops when dealing with controlled drugs (morphine, methylphenidate and so on) that I may have well trained as an acrobat rather than a pharmacist. One measure that has been introduced is running balances for our registers (though just good practice at present). Now this has caused some changes to be made. In the past there would be one register for all morphine preparations and one for all methylphenidate preparations. Now we have one register for each morphine preparation - so there is one for morphine 10mg modified release tabs and one for morphine 100mg modified tabs.

The pharmacy I have just started managing introduced running balances in July. Not much time for things to go wrong? If only. When reconcilling theroetical balances with actual stock there were about ten items that were wrong, and there were locums who did things like adding Durogesic 25mcg patches to Durogesic 12mcg patches. And lots of pharmacists can't add up: 134 - 30 = 104? not according to some.

So after lots of fun checking through invoices and looking through patient medication records I managed to sort most of the problems out. However there were some which I couldn't solve and have had to adjust the balances. In two cases we actually had more stock than we should have. I'm not too bothered about that. In two other cases I had less stock than I should have had. So I've sent letters to the superintendent and the owner outlining the situation and the stock levels I am prepared to be responsible for.

This mess probably took more than 15 hours to sort out, but hopefully it will all run smoothly from now. The RPSGB obviously live on a different planet as they recommend that stock is reconcilled with the running balance on a weekly basis. When am I ever going to have time to do that?

In other news, I had a meeting with the local GP surgery. They all seem very nice and were enthusiastic about MURs. They even offered to refer patients to me! They weren't to keen with me asking them to prescribe dressings and injections in complete packs - worried about their budget. In truth the impact on their budget will be minimal, especially given that I save them money by picking up people with silly prescriptions such as perindopril 2mg 2 tabs daily (for some reason the 2mg tabs are the same price as the 4mg tabs). I just hate having split packs of dressings on the shelf that are never going to be used again. Something to work on with the practice and district nurses I think.

Wales to introduce free prescriptions

2007-01-23T20:28:00.000Z

Welsh assembly members have today voted to introduce free prescriptions for everyone in Wales. All I can say is I'm glad I don't work in Wales. Prescription volumes are increasing by around 10% a year at the moment as it is, due mainly to NICE guidance and the GP's QoF points.

I agree with the arguement that the current exemption system is unfair, but the way to solve that is to review the exemption system, not give everyone free prescriptions. Giving everyone free prescriptions will, without doubt, substantially increase the drug budget in Wales. I already see lots of prescriptions for cheap items that can be purchased cheaply from people who are exempt from prescription charges. I would not be surprised at all if the Welsh reconsider their decision within a year.

An article in the Pharmaceutical Journal discussed the cost of low dose aspirin to the NHS. To purchase a year's worth of 75mg aspirin costs around £4.50. If you get aspirin on prescription it costs in the region of £2.50 per month (£1.37 per 28, plus a 90p dispensing fee, plus 3.24p container allowance, plus various practice allowances.) So, if people can get something for free they will, which is why Wales will change their mind.

Vitamin D for prostate cancer

2007-01-22T23:33:00.000Z

Interesting story here about using vitamin D to treat prostate cancer. In small scale trials patients taking the drug lived for an extra nine months. It is questionable how this will translate to larger trials as patients did not recieve optimal treatment with taxotere.

So much change

2007-01-17T19:48:00.000Z

Having survived the annual chaos that is the Christmas period in primary care, is there any chance of me being able to sit back and relax? Not a chance! Firstly I've just moved in to a company flat and although I should be used to moving by now (eight addresses in six years) it's still a pain. Especially when you don't have internet access for a week and have the best part of 200 emails to read through.

But moving house was the easy part, compared to managing a new pharmacy which hasn't had a manager for a few months. So I've got stacks of paperwork to sort out and staff to get to know, as well as dispensing and checking. This pharmacy is very busy front of shop, and is doing c10,000 items a month. If the GPs were to switch to 28 day prescribing this would probably leap to 15,000 or more. I do have some help however in the shape of a shop manager who can take care of a lot of things for me. So although I've been thrown in at the deep end somewhat, with no management training or experience, I have got a bit of a lifejacket. Best of all, I am thoroughly enjoying it. I have a good set of staff, with all three dispensers working towards their NVQ 3s and the GPs actually phone me back within 15 minutes or so for non-urgent queries.

My long term plan for the pharmacy is to get one of the dispensers trained as a checking technician so that I can use my time speaking to patients and carrying out services. I'd also like to get the GPs to change to 28 day prescribing which will increase our workload (and income), but make it easier to manage stock levels. At present we run out of amlodipine 5mg, simvastatin 40mg, ramipril and so on because we haven't got the space to store the stock needed. I've had scripts recently for 500 oxytetracycline, 400 erythromycin and 504 metformin! I expect the GPs to be a bit resistant to this change, however there is a way of implementing it that will actually decrease their workload: repeat dispensing. This means if a GP decides a patient is stable on their medication at a review they can issue prescriptions there and then to cover the patient until their next review is due. This means no need to sign repeat prescriptions every month, so reducing the GP workload, and means that I can see which patients are due for their prescriptions and when, and actually plan my workload.

The is just one fly in the ointment at present: the local dentists. Although they are allowed to prescribe a wide range of drugs, I am sure dentists get very little training in therapeutics. I spoke to one of them recently about a prescription for metronidazole 400mg to be taken four times a day (it's normally three times a day and has a half life of around 8 hours). Neither the British National Formulary nor the Medicines Compendium mention four times a day dosing, and if it isn't mentioned in one of those sources it's a strange dose. So I spoke to the dentist about this, I was told to leave it a four times a day. When I asked if there was any particular reason why (like some really nasty infection that only dentists see and no one else knows about) I was told 'because that's how I want it.'
So I told the patient that their dentist wanted them to take this antibiotic four times a day, but added that it's always three times a day, and that's what I would do. I then wrote the dentist a lovely letter, asking for any evidence they had to support the use of metronidazole four times a day. Still waiting for a response...

The week before Christmas

2006-12-23T16:51:00.000Z

Am I glad this week is over? Oh yes. Anyone who knows anything about community pharmacy will know that this is the busiest time of the year, along with Easter. For some reason people go crazy and panic, and seem to think the GP surgery is closed for four weeks and the pharmacy closed for three weeks, as opposed to four days and three days. This week I've been working at what is already a busy pharmacy, and it has just been non-stop over the last week. They are on schedule to do 20,000 items in December. At least the boss will be happy.

I was expecting the pharmacy I was at today to be busy, given it's the last day they are open before Christmas, but it wasn't too bad, and I only had to make one emergency supply, which must be some kind of record. Just as well it was a Saturday though, otherwise I'd probably have spent half the day on the phone to a GP, trying to figure out why he had given three months worth of Crestor 10mg daily to a lady who hasn't been on any other statin, and who hadn't even been told what their cholesterol was.

So, I've got a couple of days off, and some time to get acquainted with a good bottle of Scotch and some good books, before turning my attention to the changes that are coming my way next year.

Astra Zeneca to follow in Pfizer's footsteps

2006-12-13T20:03:00.000Z

Pfizer recently announced plans to change the way their medicines are delivered to pharmacies, hospitals and dispensing doctors, as reported here and here. Pfizer are changing from the current and successful model where manufacturers sell their products to wholesalers, who then sell it on and deliver it, often twice daily, to pharmacies. Pfizer want to introduce a system where pharmacies purchase direct from them, with deliver by one company. In this case it happens to be Unichem, the wholesale arm of AllianceBoots. There has been much debate in the letters of the Pharmaceutical Journal over the impact this move will have.

Well, surprise surprise, another company, Astra Zeneca, have decided to follow in Pfizer's footsteps, as reported in The Times. If these distribution arrangements are allowed to stand, it is likely that other manufacturers will jump on the bandwagon. This would be disastorous. The current model is resilient and works very well. The proposed model is anticompetitive and will not have the resilience of the current system. The future of independent regional wholesalers would also be in doubt as it is easier to make a profit on branded drugs as opposed to generics. Oh, and spare a thought for us poor overworked pharmacists. At present I only have to deal with one wholesaler, a regional independent wholesaler which is part of the company I work for. If anything is out of stock at the warehouse it is automatically ordered from Unichem or AAH by head office. My life is very simple at present. If Astra Zeneca use AAH as their delivery agent, and Sanofi choose Phoneix, Lilly someone else and Novartis yet another company, then ordering will be made so much more complicated and time consuming. And it's not like I don't have enough things to do as it is.

Thankfully, some MPs are on the ball, and have signed a motion opposing Pfizer's move. This system will be bad for the NHS, bad for pharmacies and most importantly of all, bad for patients. Please write to your MP and let them know how concerned you are about this.

The RPSGB: to split or not?

2006-12-12T19:28:00.000Z

The Royal Pharmaceutical Society is a unique body in healthcare. It is responsible for both regulating and representing pharmacists. Doctors have the GMC to regulate them and the BMA to represent them, while nurses have the NMC to regulate them and the RCN to represent them. Pharmacists just have the RPSGB. The Society was founded in 1841 by Jacob Bell with the aims of 'uniting the profession into one body, to protect its members' interests and to advance scientific knowledge'. Regulation was added on in 1868 and was built upon, culminating with the Pharmacy and Poisons Act in 1933 which established the Statutory Committee as a disciplinary body.

Although the Society was originally established to represent it's members, it seems to have been focussing more on regulation than representation. The Statutory Committee has a far better reputation as a disciplinary body that the GMC, and you can take a look at its decisions here. The representative side seems to have slipped somewhat recently. The BMA and RCN are both far more effective as representative bodies than RPSGB. How often do you see pharmacists in the media, compared with doctors and nurses? And consider the extension of prescribing powers to nurses and pharmacists. This was announced in November 2005, after a long consultation. Nurses were ready to go almost straight away and I've already seen quite a few prescriptions from nurses. It took the RPSGB until August 2006 to come up with a curriculum for pharmacists to train as independent prescribers: almost a year!

The Society needs to cast off the regulatory role and get back to doing what it was originally founded to do: represent pharmacists. This needs to be done as soon as possible, to protect the assets of the members before the government tries to cream them off. Individual pharmacists also need to blow their own trumpet more. This article about nurses applies even more so to pharmacists. Some community pharmacists also monitor warfarin therapy, and are better placed than nurses to do so, due to our education and we do not need lots of specialist training.

Pharmacists need to claim back our Society, grab any opportunities that come our way, and let the public know what we do.

Continuing professional development

2006-12-12T19:15:00.000Z

It is a requirement in the Pharmaceutical Society's Code of Ethics that pharmacists undertake continuing professional development. CPD includes continuing education (doing courses, going to workshops, reading articles etc), but takes it a step further as you have to consider what impact your learning has had. I do not have a problem with keeping up to date; I read journals, go to workshops and am doing a postgraduate diploma. What I do have a problem with is the way CPD has to be recorded. You have to complete sections on reflection, planning, action and evaluation. The Society has set up a whizzy website to help pharmacists and registered technicians with CPD, but it is just so slow. My first CPD entry took well over an hour. I am pushed for time as it is, why can't the Society treat its members like adults and just allow them to get on with their jobs.

Grand Rounds 3;9

2006-11-22T19:28:00.000Z

Here

Sources of drug information

2006-11-18T23:25:00.000Z

My two most used sources for drug information are the British National Formulary and the electronic Medicines Compendium. The BNF is a joint publication of the Royal Pharmaceutical Society and the British Medical Association and is sent to every pharmacy and GP. It is the first point of call in the UK for drug information. The website is good, but registration (free) is needed for access. The eMC contains both summaries of product characteristics and patient information leaflets. SPCs are a summary of the information provided when a drug is put forward for marketing, and are the basis of the information in the BNF. The problem with eMC is that you can't link to anything which makes it useless for linking to information in blogs like this. It can also be somewhat patchy when it comes to drugs only available as generics.

There are a couple of US sites which seem fairly good from what I've seen, namely drugs.com and Rxlist. The problem with these sites is that drugs are often marketed under different names in different countries (i.e. omeprazole is Losec in the UK and Prilosec in the US), and may also have different licensed doses and indications. Of course, this assumes that a drug available in the UK is also on the market in the US.

My first choice would have to be the eMC, if only you could link to SPCs and PILs on the site.

Medicines Use Reviews

2006-11-18T22:14:00.000Z

When the new contract for community pharmacy was introduced in 2005 it included medicines use reviews (MURs), designed to get pharmacists out of the dispensary and talking to patients (link opens PDF). MURs are designed to improve patient knowledge, concordance and use of medicines. Pharmacists have been slow to offer MURs, partly because of the copious amount of paperwork required with the new contract and the need for accreditation of both pharmacists and pharmacies. The reaction of some GPs has been less than complimentary. The best way to prove these GPs wrong is to produce some good quality MURs.

As part of a post-grad course I'm doing I had to conduct five MURs. So what came out of them? Well one of them was checking the patient was taking her medication correctly and knew what they were for, but then she was on nine oral medications, five of which were for high blood pressure. To go any deeper in this case would have been far outside the scope of MURs. Another of the MURs was educating a patient about asthma, including the need for regular use of preventer inhalers and allaying fears over long term use of inhlaed steroids. Next up I had an elderly gentleman who was taking diclofenac and omeprazole. Except he wasn't taking the omeprazole, so he had no protection for his stomach from the diclofenac, and he was wasting NHS money. So I explained the reason for taking omeprazole was so that he didn't end up with a nice gastric ulcer, and hopefully he'll take them from now on. I then saw a patient who was being prescribed standard release dipyridamole twice daily, when she should have been on the modified release product if she is taking it twice a day. This patient is also on low-dose aspirin, which increases the risk of gastric ulcers, but is not on anything to protect her stomach, so I suggested her GP start omeprazole 20mg daily. The final patient I saw had some fairly easy things to change to make her life easier, such as changing from simvastatin 20mg 2 at night to simvastatin 40mg 1 at night. This patient was also on co-amilofruse, a combination of furosemide and amiloride. Very few people actually need the amiloride and this patient could not remember having any blood test, so I suggested the GP review the need for the compound product. This patient was also taking Nytol (diphenhydramine) every night without her GP's knowledge so this was passed on to her GP.

From five MURs I found three people that either weren't on a gastroprotective agent or weren't taking it properly, three cases where formulations or strengths should be changed and one case where someone was taking regular over the counter medication that her doctor should have known about. I also had the oppourtunity to educate these patients about the use of their medicines and their disease states which is always beneficial. Hopefully this shows that MURs are beneficial for patients and are not just more paperwork for GPs to read. If anyone in the UK wants to make their pharmacist happy, and probably surprised, go and ask for a MUR.

Ask About Medicines Week

2006-11-07T20:32:00.000Z

This week is Ask About Medicines Week,
with an overall theme of asking about medicines as we get older. There are many commonly used medicines that can be dangerous in the elderly. In particular, aspirin and anti-inflamatory painkillers, such as ibuprofen, must be used with great caution given that they can cause stomach ulcers and can precipitate renal failure and heart failure.

It should not however take a PR campaign to encourage people to ask about their medicines. If patients have any questions about their medication they should feel free to ask their pharmacist, and pharmacists should be checking whether patients have any questions.

Bad pharmacists

2006-11-02T22:26:00.000Z

Bad pharmacists really irritate me. I got a prescription for my partner at 9:30 tonight, from a 100 hour pharmacy. The script was for Naproxen 250mg, one three times a day, and Co-codamol, 30/500mg, two four times a day. Now my partner has never been to this pharmacy before, so the pharmacist didn't know if these drugs had been taken before. But what happened? The prescription was dispensed and handed to me with absolutely no adivce whatsoever. This is unacceptable. It's not as if the pharmacy was busy - I was the only one anywhere near it, so it must be either laziness or incompetence. Either way it's just not good enough. Both of these drugs need counselling on, or at least checking if they have been taken before. Co-codamol can cause drowsiness and constipation, and contains paracetamol, while naproxen needs to be taken with food. Naproxen is also in the same group of drugs as ibuprofen, so it is important that they are not taken together. There was also no patient information leaflet with the naproxen - it is now a legal requirment to supply a PIL with all dispensed medicines. I think I might be phoning the manager tomorrow to complain, as this is just not on.

Documenting interventions

2006-10-27T21:14:00.000+01:00

Community pharmacists are supposed to record the interventions they make, at least the most significant ones. This is not always easy! On Thursday I was at a busy pharmacy with just myself and a trainee dispenser in the dispensary. We were non-stop all day, so I didn't really have time to stop and document the interventions I made. There were a few really good interventions I made, which demonstrate the value of community pharmacists:

1) An elderly gentleman attempting to purchase a bottle of gaviscon for heartburn he was getting. On further questioning he had not experienced this heartburn before, and was also taking etodolac (Lodine, a non-steroidal anti-inflamatory drug). There are several sinister conditions that can present as heartburn, particularly peptic ulcers (commonly caused by NSAIDs) and gastric cancer. So this gentleman set lots of alarmbells ringing. I referred him to his GP, who told him to stop the etodolac and gave him some omeprazole.

2) Another elderly gentleman, this time complaining of a cough. He wondered if it could be caused by the salbutamol he had recently started taking. Further questioning revealed he was also taking ramipril, an angiotensin-converting enzyme inhibitors. A persistent dry cough is a classical side effect of ACE inhibitors, so this gentleman was advised to make an appointment with his GP to change his antihypertensive medication.

3) A prescription that had so many problems its tough to know where to start. The sript was for:
- bendroflumethiazide 5mg 1 daily x56
- allopurinol 100mg 1 daily x84
- irbesartan 300mg 1 daily x56
- lansoprazole 15mg 1 daily x 56
- arthrotec 75mg 1 twice daily x 60

So this gentleman's medication was all out of synch, with one month of one, two of a few others and three months of another. Now bendroflumethiazide is effective at reducing blood pressure, and at a dose of 2.5mg per day has very few side effects. Increasing the dose to 5mg has no extra BP lowering effect, but does affect body chemistry, and in particular reduces the amount of uric acid excreted from the body. Gout is caused by high levels of uric acid, which then crystallizes in the joints. Allopurinol is used to prevent attacks of gout, so giving bendroflumethiazide 5mg to a patient with gout is not the best idea in the world.

Arthrotec is a combination product of diclofenac (another NSAID, the same group of drugs as ibuprofen) and misoprostol, a prostaglandin analogue which protects the stomach from the toxic effects of the diclofenac. Lansoprazole is also a drug which is used to protect the stomach from NSAIDs, so there is no reason to prescribe lansoprazole with arthrotec. These issues were not serious enough to warrant a call to the GP, but doing a medication use review would have been a useful way of drawing these problems to the GP's attention. As I didn't have time to spend 20 minutes or more with this gentleman and the regular pharmacist doesn't do MURs, I advised him to make an appointment with his GP for a full medication review and explained the issues to him.

Ideally I would have documented these interventions, possibly on the patients medication records. However I simply did not have the time to do so, and this is one of the major challenges facing community pharmacists today. By documenting our interventions we can show the value of our role, however there often simply isn't time to do so. This is only taking into account the major interventions, and not including all the counselling we do, such as advising patients using corticosteroid inhalers (such as Becotide) to rinse their mouth after using them, or advising patients on statins to see their GP urgently if they have any unexplained muscle pain or weakness. I think the future of community pharmacy lies in robotic dispensing, freeing up pharmacist time to speak to patients and document what they do.

Clinical pharmacy

2006-10-24T20:31:00.000+01:00

One of the problems with being a relief pharmacist is that it can be difficult to do good clinical work. Some examples from today:
1) a prescription from an extended formulary/ supplementary prescibing nurse for 56 voltarol rapid
2) a 5 day course of trimethoprim 200mg twice a day for an elderly gentleman with a urinary tract infection
3) a prescription with co-codamol 30/500 capsules, 1 four times a day and paracetamol capsules 1 four times a day.

Now none of these prescriptions is actually wrong, however there are problems with all of them. Firstly voltarol rapid (diclofenac potassium) is no more effective than standard diclofenac other than for the first few doses possibly, and is a lot more expensive. Secondly, a five day course is unlikely to cure a UTI in a male, which I told the patient. Now these are useful things to feed back to the prescriber, but not something you would phone up about during surgery and during a busy day in a pharmacy.

I did phone the doctor about the third prescription, due to the significant risk of the patient overdosing on paracetamol. It would be far more sensible, and safer, to prescribe paracetamol, 2 tablets four times a day, with codeine separately which would allow you to titrate the dose of codeine easily.When I suggested this to the GP he ignored the idea, as the patient was "happy with what he was doing." Fine, but if the same situation cropped up again I'd do the same, in the interests of patient safety.

It is far easier to feed issues back to doctors and nurses when you actually know them, and you know when is a good time to call the practice to discuss general issues. Looks like I might have to find somewhere to manage soon, so I can get more satisfaction from what I do.

Monday 23rd October

2006-10-23T23:14:00.000+01:00

Today was my first day back at work after two weeks off. Thankfully the pharmacy I was in today was fairly quiet - we did maybe 150 items today. Nothing particularly out of the ordinary came up, though I did have a prescription for three salbutamol inhalers and one beclomethasone inhaler. Except that the patient didn't want the beclomethasone, and the patient wasn't in the pharmacy, it was his wife. So I spoke to her about the need to use steroid inhalers regularly in asthma, as they help to prevent asthma attacks. Hopefully she got the message.

Now I've just found out I've got a 75 mile drive tomorrow. Great.

My first post

2006-10-16T22:53:00.000+01:00

Well this is my first ever post on a blog. I suppose I'll start by introducing myself a bit. I'm a community pharmacist who works in the south east of England for a medium sized chain. I have only been registered since July this year, so the last few months have been a bit of a rollercoster ride. I have recently started a postgraduate diploma in clinical community pharmacy which should keep me busy over the next couple of years.